Douglas Hogg: Will the Minister cause his officials to say to the US Administration that they would be better placed to lecture Cuba on human rights if they were to ensure that the detainees in the Guantanamo bay base had the same rights that they would have if they were held in the US?

Kim Howells: I certainly agree with the last part of my hon. Friend's question. I have looked very hard on my visits to Afghanistan at the story of how the Taliban stopped heroin production. What I discovered when I was out there is that they were very astute business men. They realised that the price of raw opium was pretty low. They held stocks back for a couple of years; the price shot up, and they released them. I would not look to the Taliban for any kind of moral guidance on what we ought to do about this.

Jack Straw: The hon. Gentleman raises another reason why the only salvation for Cyprus is through negotiations leading to a sensible settlement, brokered by the United Nations, and by an end to the division of the island. That is the only way in which the genuine interests of the Greek Cypriot community, including those of Greek Cypriot origin who are British citizens, can be resolved satisfactorily. The issue of compensation for land seized is central to those negotiations. Unless and until the Greek Cypriot Government, as well as the Turkish Cypriots and others with interest, get back to the negotiating table, there is in practice absolutely no chance of the hon. Gentleman's constituent receiving what is due to him. I wish it were otherwise, but the Mr. Iacovou, the Foreign Minister of Cyprus whom I saw, could offer me no alternative prospect for his own people and for solving their problems. That is why I regret very much the negative approach that that Government are taking.

Andrew Lansley: I beg to move,
	That this House notes that one in four people will suffer mental health problems; is aware that mental health trusts are facing some of the largest cuts in planned budgets whilst already having to cope with worryingly high recruitment shortages; further notes that patients with mental illness are often denied real choice in their treatments due to long waiting times for referrals and an acute shortage of non-drug therapies such as cognitive behavioural therapy; is alarmed at the particular problems experienced by black and minority ethnic patients in accessing services; is concerned at the continued absence of a Mental Health Bill almost four years after the first draft Bill was published; and calls on the Government to raise the relative importance of mental health within the NHS, making early intervention a priority in order to enable access to a range of appropriate services and urgently to publish a revised Mental Health Bill which recognises the rights and dignity of people with mental illness.
	May I say at the outset that I am sorry to hear that the Secretary of State is indisposed? We send her our best wishes. We are sure that it will be only a temporary indisposition and that she will be back performing her duties very soon. However, we are happy that the Minister of State, the hon. Member for Doncaster, Central (Ms Winterton), is here to speak for the Government on this subject, for which she is directly responsible in the Department.
	The purposes of this debate are threefold. First, given that there has been no debate in Government time on the Floor of the House on mental health services since 1997, this debate will permit hon. Members not only to assess the future of those services, but to express their appreciation of the staff who work in them and their understanding of the needs of patients with mental health problems. Secondly, we want to express what I hope will be the view of the whole House, namely, that mental health services must not be the Cinderella services of the NHS that many people have often perceived them to be. The services deserve, and must have, priority, and that priority must be reflected in the delivery of the services. Furthermore, that delivery must not be compromised—and patients must not suffer—as a result of present or prospective NHS deficits. Thirdly, we want a reformed Mental Health Bill that people across the range of mental health interests can support to be brought before the House. Such a Bill was promised in the Gracious Address, but there have been long delays. We want it to contain provisions that will provide dignity and a positive framework for those whom it is intended to serve.

Andrew Lansley: No, I will carry on with my speech, if the hon. Gentleman will allow me.
	Let us be clear that combating and overcoming the stigma attached to mental illness is at the heart of what we must do in relation to mental health services. My hon. Friend the Member for East Worthing and Shoreham and I visited the Brent Mind housing project this morning, where we talked to some of the tenants, most of whom have a dual diagnosis of schizophrenia and substance misuse of some kind. In relation to the impact of stigma, our discussion was very interesting. For example, they said that there is still a sense in which the public push the problem not just to the margins, but out of sight and out of mind. There seems to be an assumption that someone who has been mentally ill will not recover, and that the condition is permanent. That is not true. People do recover, medication is capable of assisting dramatically nowadays, and talking and other therapies can be very successful.
	At any one time, 630,000 people might be receiving mental health treatment in this country, but that is only a fraction of the number who will at some time in their lives have mental illness—probably one in four of the population will have mental illness at some time. For many, it is a very traumatic but temporary condition. Therefore, we should not treat people who have mental illness and recover any differently from those who have had a broken leg. People recover and move on. Even if people are on medication, perhaps on a more or less permanent basis, we should not treat them differently. We do not say to diabetics that because they take insulin their ability to work is necessarily compromised. We support such people, encourage them, help them into work and expect them to be integrated into society. The same should be true of people with mental health problems. Illnesses, whether physical, psychological or mental, should be treated in the same way.

David Taylor: Perhaps the hon. Gentleman is being a little unfair on the Government, who have increased resources in real terms by 25 per cent. There are now 8,000 psychiatric nurses, 1,200 consultants and 3,000 clinical psychologists. He seems to be drawing together examples from university towns—Cambridge, Oxford, Loughborough and elsewhere. Does he agree that we need to do much more in the FE and HE sectors to promote mental health? Ten per cent. of young people between the ages of 11 and 25 self harm, suicide is the cause of 20 per cent. of the deaths of young people and the age group that commits suicide the most is young men aged between 15 and 24. Should not more be done in that regard?

Rosie Winterton: We have been looking closely at specialist GPs, who can make an early diagnosis. We also want to facilitate the professional exchange of information, so that practitioners can look out for those early symptoms, and they can be followed up by intervention teams if people are obviously deteriorating.
	I want to address some of the points that the hon. Member for South Cambridgeshire (Mr. Lansley) made about what he called cuts to mental health services, and it will be helpful if I set out some of the facts. In response to concerns expressed in the past few months, we recently asked for information from all 28 strategic health authorities. Twenty of them reported no reductions to planned expenditure on mental health services this year; the remaining eight reported that there would be reductions in planned expenditure affecting 11 trusts—11 trusts, of 84 trusts in England. Those trusts had planned to spend £894 million this year, and they are reducing their planned expenditure by a total of £16.5 million—2 per cent. of the total.
	To summarise, 11 of 84 trusts are making expenditure reductions that amount to £16.5 million out of a total expenditure on mental health of more than £6 billion—0.3 per cent. of the total. Of course, in the light of the extra investment that we have made, we would prefer it if there were no planned reduction in expenditure. However, I hope that I can assure right hon. and hon. Members that strategic health authorities are working with those trusts to minimise any impact on patient services.

Diana Johnson: For three years, I was a member of the Mental Health Act Commission. I visited patients not only to check that they were legally detained under the Mental Health Act 1983 but to talk to them about their concerns. With that experience, I am pleased to be able to say a few words this afternoon.
	Although as a Mental Health Act commissioner I was working at the acute end of mental health, dealing with people who were detained, it was interesting to talk to them about their pathways and how they ended up being sectioned. I visited not only NHS psychiatric facilities but private sector facilities. That was an interesting experience because, in some instances, the private sector can provide good facilities and meet needs where the NHS cannot.
	The right hon. Member for Charnwood (Mr. Dorrell) mentioned that the view seemed to be that, prior to 1997, things were terrible and that, from 1997, suddenly things got a lot better. The focus on mental health services has increased since 1997. The investment has gone in since 1997. When we talk to the community and voluntary sector, it says that the joined-up thinking and the investment in mental health services in local communities has been staggering in some instances. From my right hon. Friend the Minister, we heard that there are 8,000 more psychiatric nurses, 1,200 more psychiatric consultants and 3,000 more psychologists. Those are real people providing a real service to our constituents with mental health problems.
	The most important thing that Labour has done is the 1999 national service framework on mental health services, which set the gold standard for what we should be looking to achieve in all our mental health services. I want to talk about child and adolescent mental health services, women patients in mental health services and the NHS estate in terms of psychiatric units.
	On children and young people, on Friday I went to a meeting of the Humber mental health trust, a three-star mental health trust that does excellent work. It said that, although the national service framework for adult mental health services—it includes sections involving children—was a good start, we needed an NSF for young people. The chief executive said that the split between children and adolescent mental health services that goes up to 16 or 18 years of age was not providing the kind of care we should be providing for young people. We need a service that spans the age group from, say, 15 to 30.
	We need to make sure that, for younger children who may come into contact with mental health services, their contact is community-based. We must keep young people away from the acute sector because it is not an environment where we want children and young people to enter unless there are extreme circumstances. The facilities are not suitable for them. There are some disturbed people in our facilities and we need to keep our focus on the community setting.
	Getting in early is important. I was pleased to see that Sure Starts were putting emphasis on developing emotional well being in the support that they are providing to parents and carers of our youngest children. Such guidance to those who look after children uses creative activity to improve children's self-esteem, social skills and emotional well being. That is absolutely right. It is a stark fact that a child living in a low-income, lone-parent household is twice as likely to have emotional disorder as a child in a two-parent family on a reasonable income. There is a clear link with poverty and it is right that Sure Starts, which were based on the most disadvantaged areas, are putting the focus on emotional well being.
	I want to talk about Mind, which provides excellent services across the country for people with mental health problems. In my constituency, the Linx project provides help with housing and independent living for young people who have shown the first signs of psychosis. Getting in early and investing early in our young people means, we hope, that they can go on living independent lives and putting their problems behind them.
	We have heard about the massive investment in PCTs for mental health services and it is worth putting on record that £300 million has gone into PCTs and local authorities to improve child and adolescent mental health between 2003 and 2006. However, there are still some gaps. I visited Hull domestic violence refuge and was told by some teenagers that there were counselling facilities available to younger children to help them deal with the trauma they had experienced, but that there was nobody to provide teenagers with counselling. I hope that we put some work into that area. It may be that we invest now to save later on.
	I want to pay tribute to the work done in Scotland in the one in four campaign, which is trying to remove the stigma from mental health. Hon. Members will agree that that is a good campaign. In Australia, the National Youth Mental Health Foundation has been set up and is looking to make sure that money is put towards young people suffering mental health problems. We need to ensure that particular resources are attached to making sure that those in the 12 to 25 age group get the help they need. Of course, the recently published Health White Paper will work to counteract the stigma of mental health.
	I turn briefly to safety, which is a real issue for women in-patients in mental health facilities. As was pointed out earlier, there can often be a mixture of people with various mental illnesses and disorders on a given ward. It is important that women, who can often be very vulnerable, are provided with separate facilities. We have a commitment to providing gender-specific facilities and I hope that more resources will be put into providing them throughout the country.
	We also need to consider the estate. Statistics show that only 35 per cent. of psychiatric intensive care units have en suite facilities, that 25 per cent. have no enclosed garden space and that 35 per cent. have no gender- specific facilities. We need to get these issues right. A decent standard of accommodation can have a very positive effect on the recovery of those suffering from mental illness or disorder. I am pleased to note the massive investment that has already gone into improving in-patient facilities, but there is still more to do.
	I am pleased that we have made a positive start and it is indeed since 1997 that we have really focused on this issue. We need to keep working on provision for children and young people, because there is more to do in that regard. As part of our wider public health agenda, we need also to deal with the issue of emotional well-being throughout the whole of an individual's life.

Angela Browning: During this debate, which I very much welcome, we need to reflect on the scale of mental ill health. We are told that one in five adults will experience mental health problems at some point in their life, which means that, of the 20 Members currently in this Chamber, four of us could well experience such problems. It is very unlikely that the same ratio of Members will experience any other type of health problem.
	As with many other conditions, mental ill health does not affect just the patient. The impact on families, particularly the prime carer, is enormous; indeed, it is so great that, ultimately, it can affect both their mental and physical health, particularly if that patient has a long-term condition. Many of us—certainly me—have experienced at first hand in our families the agonising condition of mental ill health and its impact on people's lives. It is one of the most distressing conditions.
	In discussing mental health, I want to focus on the two age extremes. Many Members have mentioned young people, and at that age suicide is an issue. The Mental Health Foundation and Mind have pointed out that the highest rate of suicide is among young men between the ages of 15 and 24, that 20 per cent. of all deaths among young people are through suicide, and that one in 10 of 11 to 25-year-olds self-harm. Given the scale of the problem, we have to find the answers and the policies to alleviate it. Behind those bare statistics are very real tragedies for the families concerned.
	It would be remiss of me not to add one more statistic on behalf of a group of people whom I mention probably far too often in this House. However, I make no apology for doing so. A recent report by the National Autistic Society pointed out that the attempted suicide rate among adult sufferers of Asperger's syndrome is 8 per cent., which is very high indeed. When we consider, in managing such patients, how they reached the point of attempting suicide, there is usually—not always, but usually—an identifiable pathway in their relationship with the statutory services.
	In the recent past, I have had more than one Adjournment debate on in-patient deaths within the Devon Partnership NHS Trust. I wish to put on the record that since I have raised the issue and some of the concerns have been addressed, we have seen—under the management of Mr. Iain Tully and his team—a real rethink on why those tragic deaths occurred in our area. The mother of one of the young men who died showed me a plan of his relationships with statutory services during his long history of mental ill health. The relationship usually started well, but eventually failed. We euphemistically call that falling through the net, but too many young people do so—especially in their relationships with community services.
	I wish to pick up a point made by the hon. Member for Northavon (Steve Webb). Often, the first professional a patient sees is their GP. I sympathise with GPs because they have an eight-minute slot in which to listen, assess and decide what to do. There are GPs in my constituency—and I am sure they are not unique—who ask how they can do anything other than pick up the prescription pad at the end of the eight minutes. A prescription may solve a short-term problem, but—and I mean no disrespect to GPs—it does not address the underlying cause. Many of the young people who end up as suicide statistics do so because not enough time has been spent with them, there has not been enough continuity in their care and the people who could help are not out there in the community.
	My hon. Friend the Member for South Cambridgeshire (Mr. Lansley) pointed out that when people break their legs, they recover. Well, people do make full recoveries from certain types of mental illness, but mental health problems make people fragile. Such problems are often recurring. Also, when people present to GPs and other professionals, their instinct is often to conceal the underlying problem. It often takes many hours of discussion and counselling before even the best trained psychiatrist can start to identify the right approach for an individual. It is time-consuming, painstaking work that is very different from other areas of medicine. Therefore, while I understand the Minister's wish to put the statistics in the best light possible, we still have a huge way to go. The suicide statistics prove that.
	At the other end of the age spectrum are the elderly. The mental health of many elderly people breaks down from a simple cause—social isolation. To put it more simply, the cause is loneliness. Many elderly people who are unable to get out and about, or whose family and friends have started to die off or have moved away, spend far too many hours on their own, and that inevitably leads to depression. As we know, depression is a spectrum. It can be intermittent and addressed by medication, but all too often it leads to more serious mental health problems. Depression is also a common side effect of other physical conditions, such as Parkinson's disease. It is extremely difficult to disaggregate the depression and the underlying mental health problems from the physical conditions in elderly people who are often not able to be very good self-advocates. I can think of some of my elderly relatives who always put on their best face when the doctor came to call—a natural response for that generation—even though they had problems that the doctor needed to know about. It is a complex and grey area, which is not easy for professionals, let alone politicians, to enter.
	More than 13 per cent. of the NHS budget is devoted to mental health services and I am concerned about care in the community. We have heard much about the packages to deal with people's physical needs, but if we are to move towards more people being cared for at home for longer—as we certainly are in Devon— especially when they are extremely dependent physically, their emotional and psychological needs must also be met—otherwise, many elderly people will develop serious mental health problems. All too often when serious problems occur, whether with younger people in suicide cases or with elderly people with mental illness—the health service has to respond to a person in crisis. The statutory services have to respond suddenly to situations where, to put things in crude financial terms, much more money will have to be spent than if there had been regular, lower-level interventions at an earlier stage.
	There is a dilemma. Health authorities and social services departments work on annualised budgets and the system mitigates against such regular interventions. It has to deal with people who are in crisis, so it is easier to pare off services and facilities that may be regarded as low level, even though they might have ensured that many people who appear in the crisis statistics had a better quality of life and did not succumb to mental illness. The fact that more people have been admitted to mental hospital since the implementation of the Mental Health Act 1983 is an indication that intervention takes place only when there is a crisis. We must address that issue. Crisis management is never the most effective outcome, for either the patient or the system.
	As I said earlier, I served on the scrutiny Committee on the Mental Health Bill, so it would be remiss of me not to mention my grave concern about two aspects of the Bill; indeed, the Minister would expect me to do so. I still believe that the Government's broader definition of mental disorder is wrong and if the Bill is introduced I hope to put my case to the Minister even more robustly than in the past. I urge her to reconsider that aspect of the Bill.
	My second concern relates to compulsion. We received evidence from the Royal College of Psychiatrists that, under the provisions, we should need to detain one in 2,000 people with no previous indication that they would cause severe harm. I realise that the proposal came from the Home Office rather than the Department of Health, but if we broaden the definition of mental disorder so that it is based not on clinical diagnosis but merely on behaviour, and if that is accompanied by wider provisions in civil legislation for indefinite detention, the infringements of civil liberties that we have discussed in this place in the past will be as nothing by comparison. If the Minister does not address that aspect of the Bill, the rebellion will not be merely in this and another place; people will march in the streets.
	I urge the Minister to reconsider those two fundamental rights, on both of which the scrutiny Committee made firm recommendations. Together, those two aspects of the Bill will be a huge infringement of civil liberties.

Meg Hillier: My hon. Friend the Minister said that we need a response that stretches right across Government, and I want to address my brief comments in today's short debate to some of those issues. Last Thursday, I had the pleasure of opening an art exhibition by the Yao Yao group—a social group organised by the Chinese Mental Health Association, which is based in my constituency—and it was one demonstration of the fact that there are many ways to tackle mental health problems, not just through the health service.
	I pay tribute to the many people and organisations in Hackney, South and Shoreditch and Hackney as a whole—such as Mind and the Chinese Mental Health Association, which put time and effort into supporting people with mental health problems—as well as the people with mental health problems who also play a key role. My hon. Friend knows of the good work done at Homerton university hospital and by City and Hackney Mental Health Trust. It is important that all those organisations play a big role in a constituency with a high incidence of mental health problems.
	I will not bombard the House with statistics in the short time that I have, but it is startling that admissions to hospital for schizophrenia are three times more common in Hackney than in England as a whole, for both men and women. I want to touch very briefly on three issues: employment, ethnicity and the impact on welfare benefits for people suffering from mental health problems. The hon. Member for Northavon (Steve Webb) rightly highlighted the need for preventive work. He said something about the Minister suggesting that everything in the garden was rosy. In some ways, I agree with him. Not everything in the garden is rosy, but it is a lot better than it was, which is a good step.
	General Practitioners in Hackney are very much at the sharp end of dealing with people with mental health problems. Other hon. Members, particularly the hon. Member for Tiverton and Honiton (Angela Browning), have highlighted some of the difficulties of dealing with mental health problems in the short time that many GPs have available. That is one of the reasons why I welcome those aspects of the health White Paper that will improve and promote community care provision at that initial presentation point.
	We all know that people with mental health problems have much more difficulty finding employment than the general population. That is so even when compared with people who are physically disabled. About 16 per cent. of physically disabled people are more likely to be unemployed, compared with 50 per cent. of people with mental health problems. Some 86 per cent. of people with longer-term mental health problems are unemployed. The other side of the coin is how employers react—only 37 per cent of them are prepared to consider employing people with such difficulties.
	I am very proud that the two local mental health trusts—East London and the City, which covers Hackney, and North East London—the local strategic health authority and South Bank university have joined forces to fund a consultant occupational therapist for employment. I hope that my hon. Friend agrees that that is the sort of joined-up government to which she referred in her comments. The two mental health trusts have adopted a joint partnership approach—the roots to employment project, which is the first of its kind in the UK to help people with mental health problems into work, by working with employers to ensure that they address the issues and understand the need to help people with mental health problems back into the workplace.

Caroline Flint: I am afraid that I am not going to give way because I do not have a great deal of time and the Minister of State, my hon. Friend the Member for Doncaster, Central (Ms Winterton), took many interventions earlier.
	In the seven years since the national service framework was introduced, ambitions have been surpassed in many areas, but I am the first to admit that a great deal more remains to be done. There is consensus across the House in congratulating and thanking all those who have worked so hard to make these reforms happen. I hope that we are moving towards a system of community care, supporting people in their own homes and working to increase inclusion and decrease stigma. It is equally important that a full range of high-quality in-patient services are there for those who need them. We have recently concentrated particularly on getting the balance right in that respect.
	One of the ambitions of the White Paper that we launched last week is to engage with the issue of services that could be provided outside hospital. As the Minister responsible for public health, I fully take on board matters to do with prevention and public health for those with mental health problems, as I would with anybody in the community. That is at the heart of our desire to bear down on the health inequalities that still exist. We have made considerable strides towards high-quality mental health services, but we have an even more ambitious direction of travel. We are committed to supporting good mental health throughout the population and improving preventive mental health services in the community.
	I turn to the points raised in the debate. I agree with the hon. Member for Northavon (Steve Webb) that it is important to integrate health and social care budgets. The White Paper sets that out very clearly. We can do plenty more work in that area, which creates opportunities for innovation and imagination.
	The hon. Members for Northavon and for Banbury (Tony Baldry) talked about GPs. Practice-based commissioning will help GPs to manage more effective care pathways and allow primary care trusts to commission new services on behalf of GPs. Coupled with an enhanced role for GPs in managing mild to moderate depression in better monitoring mental health, we hope that this will create more flexibility and incentives for GPs and PCTs to manage mental health.
	The hon. Members for Northavon and for Tiverton and Honiton (Angela Browning) mentioned the new Bill. They are right to say that it will require a careful balance between a person's right to make decisions about themselves and society's duty to protect people with serious mental disorders from harming themselves, or occasionally others. We are confident that our Bill will achieve the right balance, but I am sure that my hon. Friend the Minister listened carefully to the points made in the debate.
	Members asked about prisons as places of safety when there is a crisis situation. Last year, we announced £130 million to help trusts to create proper places of safety for those who need a settlement under the Mental Health Act 1983 instead of relying on police cells or accident and emergency departments. There has been considerable work within A and E departments to improve the relationship with social services on quick referrals. On prison health, 360 mental health in-reach staff are in post, exceeding the commitment to 300 in the NHS plan. NHS mental health in-reach teams now provide services in 102 prisons. Again, there is progress but more to be done.
	My right hon. Friend the Member for Oxford, East (Mr. Smith) and the hon. Members for Banbury and for Cambridge (David Howarth) mentioned particular issues in Oxford and Cambridgeshire. I congratulate my right hon. Friend on the three-star trust rating; I am glad to hear about that progress. Last week, the Department issued a set of financial rules for the next financial year, requiring local health economies to develop an operating surplus to create a buffer against unplanned financial problems. We will work hard with NHS bodies to ensure that good finances are in place over the next few years. If we act now, we will help to better protect mental health services against the pressures that some have faced this year. That is an important challenge that we must face up to.
	The hon. Members for Cambridge and for Banbury asked about payment-by-results work for mental health. We agree that that is an important issue, and we are working hard to tackle it. We have set out our intention to pilot a new currency in 2007–08, and the move to develop a tariff is being taken forward by the mental health team. We take the matter seriously, but we are not launching an untried system on mental health services.
	The right hon. Member for Charnwood (Mr. Dorrell) made an interesting speech in which he talked about the integrated delivery of care. That is indeed vital to good services for patients. However, he failed to talk about how in 18 years he missed the opportunity to put some of his ideas into practice.
	My hon. Friend the Member for Kingston upon Hull, North (Ms Johnson) made a good speech in which she acknowledged the investment and the changes in attitudes and culture when providing services. However, she was also challenging. We have asked Professor Louis Appleby to co-ordinate children, adult and elderly people's services. I believe that to be important. We have a national service framework for young people's mental health, which outlines standards for services and, indeed, sets world-class standards for their provision. Of course, we must ensure that they are delivered on the ground and we want the help of colleagues from all parties to hold agencies to account for that.
	My hon. Friend also made good points about women. We have issued guidance on ensuring that in-patient services are safe for women—we take that seriously. My hon. Friend and the hon. Member for Northavon made points about mixed-sex wards. Ninety-nine per cent. of wards are not mixed sex—they have separate sleeping and bathroom facilities. However, we are working to improve matters. Sure Starts and refuges have an important role to play as first contacts for many women—and their children—who may suffer from mental health problems.
	I stress to the hon. Member for Tiverton and Honiton that we are spending £60 million on pilots to protect older people's health and we are piloting new centres for older people's services, which will include work on tackling loneliness. She made a valid and interesting point.
	My hon. Friend the Member for Hackney, South and Shoreditch (Meg Hillier) was right to say that we must tackle the problems of stigma that prevent people from getting work. I hope that we can consider better methods of challenging those problems through the pathways to work programme. She also made points about ethnic differences. The issues are complicated but we have done some work on examining the reasons for problems that mean that some people from black and minority ethnic backgrounds are deterred from coming forward until their illnesses are more severe. I congratulate her area on tackling those problems, and my hon. Friend the Minister of State, Department of Health, the hon. Member for Doncaster, Central has promised to visit.
	The hon. Member for Rugby and Kenilworth (Jeremy Wright) spoke about post-traumatic stress disorder. We acknowledge the importance of that work. We have evidence of what works from the National Institute for Health and Clinical Excellence and we have issued advice to all GPs in the NHS. That was invaluable in providing support for victims of recent tragedies such as the bombing on 7 July, when different agencies, including the voluntary sector, came together to help with the obvious need for counselling and support.
	I shall not specifically answer the points of the hon. Member for East Worthing and Shoreham (Tim Loughton) because, if he reads my hon. Friend the Minister's opening speech, he will realise that she covered them. However, I stress that mental health has never been higher up any Government's agenda. The result has been record increases in investment and staffing. Thanks to the efforts of the staff, front-line services have become more responsive.
	We remain some way from fulfilling all our ambitions but, based on what we have said today, I urge hon. Members to vote against the motion.

Question accordingly negatived.
	Question, That the proposed words be there added, put forthwith, pursuant to Standing Order No. 31 (Questions on amendments), and agreed to.
	Madam Speaker forthwith declared the main Question, as amended, to be agreed to.
	Resolved,
	That this House recognises that the Government has made mental health a key priority through the National Service Framework for Mental Health and the NHS plan; welcomes the achievements set out in the National Director's progress report published in December 2004; further welcomes the record increases in investment and staffing; notes that under this Government there are now over 700 specialised community mental health teams and that suicide rates are the lowest since records began, that there are 1,200 more consultant psychiatrists, over 3,000 more clinical psychologists, and 8,000 more mental health nurses than in 1997; further welcomes the Government's five year action plan to tackle inequalities in mental health services amongst black and ethnic minority communities and its action to tackle social exclusion in mental health; acknowledges the Government's commitment to early intervention to support good mental health and improve preventative mental health services in the community, as set out in the recent White Paper "Our health, our care, our say: a new direction for community services", including by improving public understanding of mental health issues to counteract stigma and discrimination, expanding access to psychological therapies including cognitive behavioural therapy, promoting the use of information technology recently reviewed by the National Institute for Health and Clinical Excellence which supports people to take charge of their own treatment, and working with health professionals to improve standards in mental health services in the community; and further welcomes the Government's commitment to reform mental health legislation as soon as parliamentary time permits.

Stephen O'Brien: I beg to move,
	That this House believes the structures of the NHS should serve the needs of the service and patients; notes the Health Select Committee's report on Changes to Primary Care Trusts (HC 646); regrets the mishandling of the reorganisation of primary care trusts (PCTs) by the Department of Health; wishes to see administration costs minimised; further believes that structure must follow function and that the future functions of PCTs have not been clarified; further believes that strategic health authorities should be abolished; further believes that ambulance trusts should not be required to undergo restructuring unless the services themselves request it; fears that restructuring proposals will seek to mask the consequences of £1 billion worth of deficits across the NHS; further regrets the loss of morale amongst NHS staff in PCTs; and calls on the Government to enter into a new and genuine debate about NHS structures, so that the service can better meet its aim of comprehensive quality healthcare available to all, based on need not ability to pay.
	As we start this debate, let us agree about the common ground between us. Nothing that I shall say this evening undermines or undervalues the constant, dedicated and professional work done by NHS staff. Doctors, nurses—indeed, my wife is a nurse—the service's many other clinical and technical staff, porters, volunteers, cleaners, even managers and administrators—all are highly skilled and good at their jobs.
	I pay tribute to them and their work. The Opposition's job is to press the Government to optimise their support for what NHS staff do in delivering taxpayer-funded health care that is free to all who need it at the point of use. I say that with deep conviction, as one of my children recently had to undergo a serious operation at Alder Hey hospital in Liverpool. Neither he, my wife, nor I can praise highly enough all those NHS staff who were involved in his excellent treatment.
	Like the country at large, the Opposition regard the NHS as a top priority. We are optimistic about its future and determined to see it improve. It therefore comes as a surprise to most people that a great many NHS trusts face serious and worsening deficits totalling something of the order of £1 billion gross, with wards being closed and services curtailed.
	We have just finished a debate on the vital matter of mental health and, even there, cuts are being made in availability, provision and access. We are now debating the Government's latest proposed reorganisation, of primary care trusts, strategic health authorities and ambulance trusts. One fears that it is a case of the Government fiddling while Rome at least smoulders. As soon as the Government hit the inevitable choppy waters—in this case, ballooning deficits in a quarter of all trusts—that were the inevitable consequence of their own policies and targets as well as their most recently introduced organisational and structural tinkering and meddling, they reach for their reorganisation manual yet again.

Stephen O'Brien: Apart from the fact that the Government are clearly attempting to fulfil their own manifesto promise of £250 billion of cuts, the hon. Gentleman should not read so much into the note distributed to him and his fellow Back Benchers by the Labour health team, and signed by the special advisers to the Secretary of State, that tries to suggest that that is our position, not recognising that it is nothing to do with the policy that we promote.
	Quick consultations always suggest a foregone conclusion. I have been contacted by GPs in my constituency who work within the Central Cheshire PCT and who are worried that that is the case. They understand that the Government's current preferred option is that all four existing Cheshire PCTs became one, but fear that that will be too large, impacting on local links, covering different care pathways and looking to both Manchester and Liverpool, which is inappropriate for my constituents. With them, I favour Central Cheshire and Eastern Cheshire PCTs combining. They are also concerned, as are all Opposition Members, that those structural changes are a deliberate ploy by the Government to mask the consequences of deficits and their impact on patients.

Jane Kennedy: I agree with a significant part of what the right hon. and learned Gentleman said. If I can get to it, I will explain the reasoning behind the changes that we are bringing forward. I strongly disagree with him on one thing, on which I must pick him up. The only similarity between GP fundholding and practice-based commissioning is that it involves GPs. Otherwise, there is absolutely nothing in common between the two systems. Under fundholding, every GP could have a contract with any number of hospitals, wasting enormous amounts of clinical and administrative time in negotiations. Under practice-based commissioning, the PCT will hold the contract with the hospitals and the GPs will use that contract to access services for their patients. There is absolutely nothing in common between the discredited system that the Conservative party instituted and the system that we are taking forward.
	The increased investment that I mentioned earlier, together with the hard work of 1.3 million NHS staff—and I am pleased to join the hon. Member for Eddisbury—

Brian Jenkins: I have listened with interest to what my hon. Friend has to say, and I ask her please not to take any notice of the county councils on this issue. I do not understand the criteria or the figures on which such amalgamation is based. My PCT is one of the most expensive in my area. In terms of management and administration, it costs £27 a head for every man, woman and child in the area—a sum far greater than that applying to other PCTs in the region. I cannot understand why the Department is still pressing ahead with a PCT that will cover nearly three quarters of a million people and all of south Staffordshire, given that the average figure for west midlands PCTs is 230,000. I am not opposed to any amalgamation that improves services, but I want to know what the criteria are and how they have been arrived at, and how we can provide an effective local service for people on this scale. My hon. Friend has yet to make the case.

Julia Goldsworthy: I thank my hon. Friend for that contribution, and that is certainly the feedback that I am getting from my constituents. In the past, there has been a very good relationship between the local PCT and the services offered. There is real concern that a move to a bigger authority will lead to the loss of links that have been built up in the past few years, and that that will have a detrimental impact on the services provided. However, only one proposal—for a single primary care trust—has been put forward for consultation, and the argument is that it will provide a more strategic role. If that is the case, why would we continue to need a strategic health authority?
	The changes do not stop at PCTs, ambulance trusts and strategic health authorities. Other significant changes will kick in this year, including payment by results, practice-based commissioning and even the new dental contracts, which are all closely interrelated with the changes in the structures. Sir Nigel Crisp was not kidding when he said:
	"2006 will be an important transitional year for the NHS."
	That is possibly the understatement of the year.
	When I talked with the chair of an NHS trust in my constituency last week, the point was made—the Minister made it again today—that this is not a time of evolution for the NHS, but a time of rapid and continual revolution. It is unclear what the NHS will look like when we reach the end of this year. A series of potentially destabilising changes will take place simultaneously in an already uncertain climate, in which a quarter of NHS trusts already have to deal with deficits. The impact of many of the changes, even if taken in isolation, is largely unknown because many have not been properly piloted. There has certainly been no piloting of the possible cumulative impact of the changes.
	For example, payment by results will start in the next financial year, but concerns are already being raised about the tariff levels for some operations. In Norway, a system of payment by results was introduced at 60 per cent., not for 100 per cent. of care, and it was seen to create perverse incentives, so it was scaled back to 40 per cent. But this Government think that the best approach is to introduce 100 per cent. payment by results straight off, and damn the consequences—even if that may create even greater financial insecurity and instability for many trusts already struggling with deficits, and even if it will lead to incentives to give every headache patient a CT scan to add to their treatment. Such perverse incentives are like the small butterfly wings flapping that create a hurricane further down the line.
	Another example of inadequate piloting before rolling out the changes can be seen in the new dental contract. We will not know what the impact of the new contract will be until it rolls out across the country, but I know from surveying dentists in my constituency that about 75 per cent. are thinking of leaving the NHS altogether as a result. That is another unknown factor to be added to an already unstable and high-risk situation. The changes look increasingly like ingredients for a rushed recipe for disaster.
	Why the hurry and impatience from the Government? After all, they have had eight years to formulate a solution. Is it the funding time scale of increased investment in the NHS, and the looming end to increased investment in 2008, that is causing the panic? If the changes are not in place and bedded down by then, is their future success even more in doubt? Or is it the hurry to find those pesky efficiency savings demanded by the Gershon review? If so, it would explain the "any size so long as it's bigger" rationale.
	Will the savings be real, or will many of them be lost in setting up and branding the new structures? Given that many PCT mergers will have to take place in mid financial year, has the Department made any assessment of the extra costs of having to file two separate accounts, or any of the other transition costs that will result from the changes?
	It is clear that it is not the wishes of the public that are driving the changes. That is evident from the amount of time given to consultation on the changes—and often from what proposals are put forward for consultation. As I said, in Cornwall only one proposal for a single primary care trust has been put forward for consultation, so there is no choice of options for the local people.
	The Secretary of State's own consultation in Birmingham also showed that the Government's priorities for the NHS were not those of the invited public. The citizens summit in Birmingham last year showed that the public were not interested in improving contestability or even the choice agenda—especially in rural areas, where getting to the local hospital is already enough of a struggle for most people. What they were interested in was increased GP opening hours and out-of-hours provision, which the Government did away with in the most recent contract negotiations. Whatever the priorities of the public—indeed, in spite of their needs and priorities—the changes continue to be pushed apace.
	The irony is that at the end of all the changes—three upheavals under this Labour Government—we will be back almost exactly where the NHS was when Labour came to power. Bigger primary care trusts will have become like the health authorities, strategic health authorities will be more like the regional authorities that Labour abolished, and GP fundholders have become practice-based commissioners. What is even more ironic is that the Conservatives oppose the proposals that will take us back to the last days of their Government.
	Greater local democratic accountability could provide better mechanisms to reflect and serve local needs and bring the accountability for underperforming trusts closer to home, rather than centralised up to the Secretary of State. Instead of pursuing and pushing forward contestability at all costs, when the regulatory framework is undeveloped and in some cases gives private providers an unfair advantage, surely trusts would be better served through greater co-operation and sharing best practice.
	The Health Committee, in a recent report, described the changes that have been undertaken since Labour came to government as an
	"ill judged cycle of perpetual change."
	This year and future years represent a time of change and an exposure to huge risks for many NHS bodies. That in turn represents great uncertainty for NHS staff and patients alike. It is time for the Department of Health to take greater account of the needs of the public rather than the steamroller of centralised reform, which takes no account of the need for locally accountable bodies to lead locally appropriate reform and locally appropriate provision for our health services. Bigger is certainly not always or automatically better.

John Gummer: I entirely agree with what the hon. Member for Waveney (Mr. Blizzard) said, and commend him for it. The joint cross-party arrangements show how strongly we feel. I have to depart from the hon. Gentleman, however, when I talk about the strategic health authority. Five Members of Parliament for Suffolk invited their SHA to answer a series of questions, as you will know, Mr. Deputy Speaker, because you were there. The questions were answered in two ways: the SHA could not help, either because the decision was a Government one or because it was a PCT one.
	There was no question to which the SHA replied, "Yes, we can do that." It cannot do anything. There is no known position on which the SHA contributes at all. Unfortunately, it has not done the one thing it should have done—overseeing the PCTs to ensure that they did not get into the debt they are now experiencing. The fact that the SHA was unable to do that shows that SHAs have no purpose whatever.
	My PCT is very much in debt, as are all the Suffolk PCTs except Waveney. One of the reasons for that debt is that on average, under the funding formula, for every 100p we receive 90p, while Manchester receives 124p, yet we have a high proportion of old people. The formula hits us strongly; it is not entirely overspending but underfunding that has contributed to the debt.
	The unfortunate changes in the way that the funds are doled out have hit rural areas with large numbers of old people. Because of those numbers we used to receive sufficient funding, but that is no longer the case. Labour Members say that we do not have the hospital closures that used to take place, but there are two in my constituency: a full closure in Felixstowe and a half-closure in Aldeburgh. That has happened since the election.
	Interestingly enough, before the election, we were told that a reorganisation would take place and a perfectly reasonable plan was proposed that would improve patient care. I supported that plan. I took the chair of the meeting to encourage people who had doubts about it that that was the reasonable thing to do. Immediately after the election, it was announced that that plan was no good and that those involved had found a new model of patient care. That happened in two months—it was a very clever, speedy change—and during that time, PCT announced that their new model patient plan involved the closure of one hospital and the halving of the other. That was an interesting decision, but we were told that it had nothing to do with money or the general election. I found that most of my constituents were unable to take that quite as literally as it was put.
	The problem is that my constituents see a model of care that makes the NHS in my area worse than it has been for 30 years. So I thought that I would ask the Minister a series of simple questions. About a fortnight ago, I asked when the financial and management specialist team would report its findings. I just asked for the date. The answer from the Minister of State, Department of Health, the hon. Member for Doncaster, Central (Ms Winterton) was:
	"I shall reply to the hon. Member as soon as possible."
	I then asked how many people made up the team and how many days they spent investigating, and the answer was:
	"I shall reply to the hon. Member as soon as possible."
	I then asked what representative bodies the group discussed things with, and the answer was:
	"I shall reply to the hon. Member as soon as possible."
	I then asked the Secretary of State for Health:
	"what sanctions are available to her against a primary care trust and its board members should poor administration be found by the financial and management specialist team."
	Anyone would think that she ought to know that, but the answer was:
	"I shall reply to the hon. Member as soon as possible."
	I then asked:
	"will she require the NHS Appointments Commission to change its policy of reappointing chairmen and non-executive members of primary care trust boards where those appointees have presided over trusts that are failing or under investigation."
	The answer was:
	"I shall reply to the hon. Member as soon as possible."
	The Minister could have said, "Yes," "No," or, "I'm thinking about it"—but no, there is the same cursory attitude to Members of Parliament who seek information as there is to local people when they go in for consultation. The consultations are a sham, and the only intention is to reach the same conclusion as the Government have decided on anyway. To reappoint to my failing PCT the same people who have presided over the debts, which must now be paid by patients in my constituency, is a scandal.

John Gummer: I agree with what my hon. Friend said during the rest of his speech as well, which was that we should at least listen to the ambulance trusts and to others around them. It all seems very peculiar, when none of the ambulance trusts have campaigned for regional operation.
	I then asked the Minister about dentists. I said that I could not find any dentists for my constituents in the southern part of my constituency and asked him to tell me where they could be found. He sent a letter back and said, "I rang up NHS Direct and here is a series of dentists." I looked at them. Half of them no longer took NHS patients or had closed their books, and the other half of them were in Frinton. He had not noticed that there is a river between us and Frinton, so instead of the dentists being 10 miles away, they were 45 miles away, unless people can swim. That shows the Government's understanding of my locality. It was a rude letter, too, because it suggests that I could have found out the information for myself—and I probably should have done that, given the sense and intelligence of the answers that I received from the Government.
	The Government are now going back to the same pattern as the one that they abolished three years ago in many of the areas that they are talking about. As was suggested by the hon. Member for Falmouth and Camborne (Julia Goldsworthy), who spoke for the Liberal party, the Government are demanding "anything so long as it's bigger"—I am not sure that she is quite right—unless they can make it a region, when the region is the answer.
	The Government are also demanding that we should take seriously their definition of PCTs. PCTs are nothing other than the creatures of the Secretary of State, but she is busy pretending that if the PCT loses money, it is nothing do with her, nothing to do with the control from the centre and nothing to do with the SHA. She says that that is to do with the PCTs. So the Government reappoint the people who made the mistake and fine the locality for the mistake that has been made, because those sums must be found in so short a time that no sane organisation would possibly consider doing so.
	I thought that I would find out whether any Minister at the Department of Health had ever run a large organisation, and I find that none of them has done so. There is not a chief executive of any major company, nor even a chief executive of a Government organisation among them. All they have run are things that other people have decided on, and they are now asking us to believe that we should blame the PCTs for the mistakes that have been made by central Government, when those mistakes have been made necessary because central Government have fiddled the funding formula, so that in many areas, particularly in the south and south-east, we are underfunded.
	We are therefore asked to be serious about consultation. My local PCT has now consulted on three separate ways to deal with the problems of my constituency in less than 18 months, each of which is dramatically different, and we are told that each has been proposed entirely for clinical reasons. I do not believe that; no one in Suffolk believes it; not even the local Labour party believes it. The only person who does believe it is the hon. Member for Ipswich (Chris Mole), who is looking for a job. No one else believes it.
	I therefore went to see the Minister of State, Department of Health, the hon. Member for Doncaster, Central—a person whom I respect—and she turned half way through the meeting to the SHA representative and said, "Well, none of these new changes will come in until they're ready, and when they're ready and they take over, then we'll close the hospitals." She was told, "Oh no, you're wrong, Minister: we close the hospitals first, because we haven't got the money to make the changes."
	What are the changes? They are to ask for care in the community. We still do not have sufficient people to carry out care in the community now, without the changes. There are no more people to do that work in Felixstowe and Aldeburgh and along the coast that I represent—and if I may say so, Mr. Deputy Speaker, as you are unable to speak, in your constituency next door exactly the same is true. Those who can pay cannot find people to that work, and we must try to pretend that the poor in my constituency should be faced with an inferior service because money must be saved to pay for debts that now stretch back for years.
	I find it impossible to take seriously the Government on the health service. Those of us who represent constituencies such as mine know that the Government have presided over the worst changes to the health service that we can remember. I have represented my constituency for nearly 30 years, and now know that the health service that the Government leave will be significantly worse than the one that I was able to welcome when I was first elected to the House.

Paul Farrelly: After listening to the two opening Opposition Back-Bench speeches—that of the right hon. Member for Suffolk, Coastal (Mr. Gummer) and the moving contribution of the hon. Member for Lichfield (Michael Fabricant)—I hope that the Minister will not groan at a similar refrain in the latest instalment from Staffordshire.
	From previous plain-speaking encounters, the Minister and the Secretary of State will be well aware of what a prickly subject ambulances and PCTs are in my constituency and the whole of our county. However, like my hon. Friend the Member for Carlisle (Mr. Martlew), before I come to the thorny issues I will accentuate the positive. I shall not reel off reams of statistics, but spending on the NHS in North Staffordshire has almost doubled since 1997. Like for like, it has increased from £267 million in 1997 to £521 million today—a 95 per cent. increase. There is not a single MP who has not seen the benefits of such investment through their constituency casework—shorter waiting lists, fewer complaints about delays in treatment and even the odd thank-you once in a while.
	In North Staffordshire, we also have a new medical school in partnership with Keele university. New health centres are bringing better NHS care right to people's doorsteps in Newcastle, as elsewhere in the country. Of course, not everything in the garden is rosy. Like any company, a huge organisation such as the NHS always faces challenges in managing that investment, not least in the face of constant organisational change. The PCTs in my area and the university hospital of North Staffordshire face varying degrees of deficit, despite the increase in spending. That is a pressing management issue but it is important to keep the scale of the problems in perspective. There should be no short-term panic measures conflicting with investment to meet long-term need.
	In our area, we were happy to hear from the new management at the hospital last week that plans for our brand-new hospital remain on track—and rightly so, if I may be partisan for a moment as we approach the 100th anniversary of the parliamentary Labour party. The hospital is the single most important investment ever promised by a Labour Government to an area that has stuck with Labour through lean and fallow, through thick and thin.
	Aside from painful decisions about costs and deficits, there is little more disruptive and demoralising than constant, continual reorganisation, not least when the benefits are unproven, the perception is of change for change's sake, and the end result may be a reduction in standards, a loss of responsiveness and a more impersonal service in our much-envied NHS. That is where we stand in Staffordshire in respect of proposals to merge the county ambulance service into one super-organisation in the west midlands covering over 5 million people and over 6,000 square miles in all.
	My hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins), as well as the hon. Member for Lichfield, referred to the ambulance service. My hon. Friend and neighbour has done sterling work in leading the call for the Staffordshire ambulance service to remain just as it is. She is representing the concerns of her constituents in the border towns and villages of the most northerly part of the west midlands region about a reorganisation that will see yet another HQ based in Birmingham.
	Those concerns about local responsiveness are shared by people in my border villages—I will be in hot water if I do not name them all—Audley, Bignall End, Wood Lane, Halmer End, Alsagers Bank, Scot Hay, Miles Green, Betley, Balterley and Wrinehill in the constituency of Newcastle-under-Lyme. Over 3,000 residents from the villages signed a petition that I presented to the Secretary of State before Christmas. Many of them turned out last night, too, at a packed public consultation meeting in Newcastle about the changes, to support the continued operational independence at the very least of the Staffordshire ambulance service. That is a political translation of, "Hands off our ambulances."
	I shall not repeat all the arguments made so well by my hon. Friend and neighbour, but I shall give one short anecdotal example, not necessarily to compete with the hon. Member for Lichfield, but to exemplify the common-sense concerns that people have. Fortunately, I have had the need to call an ambulance only twice in my life. The first time was at a funeral in Newcastle about two years ago, when the emotion was too much for one elderly person. He collapsed with a heart attack. I and other people called 999 and got straight through. The ambulance, stationed on a street corner, arrived within four minutes and the paramedics undoubtedly saved his life.
	The second occasion was for an emergency with my family here in London before Christmas. In the early hours of the morning, I called the London ambulance brigade not once, not twice, but three times. Each time, I was held up at the call centre with the same pre-recorded message: "We apologise. We are experiencing unprecedented demand for our services." When I got through the third time, the operator told me that they had no record of the first two calls—"Probably because we get so many hoaxes," she said. The air, I am afraid to say, by this time was blue. That is one of the reasons that I have not complained. I would be very embarrassed to listen to the tape recordings. We got to the hospital eventually by minicab. I know that that night, the London ambulance service did not return calls to my mobile and no ambulance ever arrived at my house.
	I cannot draw conclusions from one experience, but I can well understand from that experience the plain, everyday concerns of local people in Staffordshire. Those concerns are heightened by the fact that, despite the widespread campaign in the west midlands by our strategic health authority, there is only one option on the table in this consultation, and we are all politicians enough to know what a shortlist of one really means. We need guarantees about the operational independence of Staffordshire ambulance service.
	Primary care trusts are the bodies that we set up just over three years ago to make the NHS more local, more responsive and therefore, in everyday terms, more efficient in meeting local needs. Here, I am glad to say that we have had more success, with the Department's help, in making the consultation more meaningful. Instead of just one option, we have two: one for the whole of Staffordshire bar Stoke-on-Trent and one, bringing me even closer in my tryst with my hon. Friend the Member for Staffordshire, Moorlands, for a merger of our two local PCTs.
	That was not arrived at without a struggle—a bare-knuckle fight would be a better description. I must acknowledge the help of Ministers in the Department, who had to remind the SHA of its duty to be fair and balanced in consultation. Nevertheless, as appeared to be the case in Waveney and Great Yarmouth, it had to be dragged kicking and screaming. It was not good enough to sing the praises of option 1—the super-sized approach—while adding a grudging PS in the first draft of the document: "By the way, here's option 2, which all the local people, voluntary groups, professionals and medics in north Staffordshire support, but we think is rubbish."
	I hope that that is not the end of it. Colleagues in the south and east of the county are also balking at being thrown into one super-PCT, and we will support them as they develop their proposals. One of the non-sequiturs used by the proponents of a super-sized PCT for the whole of Staffordshire is that outside the northern sub-region, which is identifiable in its need, there is no coherent health community. That is clearly designed to set one part of the county against another. It is, of course, patent nonsense to suggest that it is better to have one super-sized PCT covering 782,000 people—by far the biggest in the west midlands—that would then have even less in common as regards health needs. When the consultation is finished, I urge Ministers to reject that sort of reasoning and likewise to reject redrawing the NHS simply for the administrative convenience of the officials concerned.
	Much has been made, without any evidence, of the benefits of coterminosity on our patch—that is, the alignment of the PCT and county social service boundaries. My hon. Friend the Member for Carlisle mentioned the local government White Paper due this summer, which may mean that coterminosity is a transient concept. From my experience, I wish that Staffordshire social services was shaken up to be just as responsive as my local PCT. That is what the county now says that it is going to do by restructuring it to follow our district boundaries. That remains to be done. The county still has to prove that it can get it right. To use that to justify shuffling the NHS furniture into one super-sized option at the same time defies common sense, particularly given that the PCTs in Newcastle and Moorlands already work well together, and with Stoke. They are getting things right, yet follow two discrete district boundaries.
	Other claims have been made for a single PCT, but again without evidence. First, it is said that, by being bigger, it will assist the new practice-based commissioning. There are smaller PCTs in the region and that argument of convenience simply does not hold water. Secondly, it is said that a super-sized option will save on the costs of bureaucracy. That is unproven. The SHA, unable to produce the costings, has recently admitted that the two options would be financially neutral.
	That brings me to my concluding observation about the driving force behind the reorganisation—cost savings. Of course we must direct more resources to the front line—we made a manifesto commitment to save £250 million through "further streamlining"—but we must do it intelligently. It is not good enough simply to shake up SHAs, PCTs and ambulance services and say to each of them, "This is your £X million share of the cost savings to bear." It is not good enough for our regional health authority to say from on high, "This is the only option." Like other Members, my target has been the approach adopted by the SHA. I am grateful for the help that has been given by the Department in the consultation on PCTs. On that basis, I will support the Government tonight, but they must continue to listen and learn from the profound concerns that have been expressed throughout this debate.

Keith Vaz: It is a pleasure to follow the hon. Member for Wyre Forest (Dr. Taylor), who owes his parliamentary career to a successful campaign to defend Kidderminster hospital—which, I understand, is still there. He speaks with great authority on these matters.
	I am sorry that my near neighbour, the Secretary of State for Health, the right hon. Member for Leicester, West (Ms Hewitt), is not here today. I understand that she is unwell. I share a hospital with her, I share a city with her, but I did not share the meal with her last night that caused her illness. We would like her to get well soon and come back to Leicester this Friday, for two reasons.
	First, we want to thank her for the huge amount of money that the Government have given to Leicester over the last eight years. There has been an increase of about 98 per cent. in PCT funding, I understand, with three brand new health centres in the city. Two are in my constituency; one in Hamilton and the other soon to start in Charnwood. Secondly, we want to thank her for giving us a PCT that was so responsive to the needs of local people, and I pay tribute to Carolyn Clifton for her excellent work. When I and others have raised issues with her, she has responded swiftly to those concerns and provided us with the services that we need.
	That is why I am so surprised that the Government wish to reorganise the PCTs in Leicester when they are doing so well. We have a particular expertise in our part of the city, where we deal with problems different from those encountered by those who live in the constituency of my right hon. Friend the Secretary of State.
	With things going so well, so much more money being provided and the PCT being so responsive, I am surprised that the Government feel it necessary to merge the two organisations. I am sure there is a justification—I have heard a justification made on the grounds of money—but there is not a justification in terms of responsiveness to the local community.I hope that when the Under-Secretary of State for Health, my hon. Friend the Member for Birmingham, Hodge Hill (Mr. Byrne), replies, he will give more of a justification than saying that it will save £1.5 million a year, or whatever it is. In a budget so vast and ever-increasing, that sounds like a small amount of money, given that we spent much more than that when we set up the PCTs a few years ago. I hope that we will have a response that justifies that decision.
	I am concerned about the abolition of the Eastern Leicester PCT because I am worried about the pathway project, which is central to the rebuilding of the hospital in my constituency, the Leicester general hospital. I have now represented Leicester, East for almost 20 years and I was promised—as were the other right hon. and hon. Members who have represented the city for a generation—that we would have new hospitals as a result of the pathway project.
	I understand that because of the reorganisation, the pathway project in Leicester is now on hold. That means that the investment of £761 million that was to be made in the NHS in Leicester will not now take place. That means that we will not get a new Leicester general hospital, nor the extra cancer facilities that we were promised, nor the new children's hospital, which was to be based in Glenfield, in the constituency of my right hon. Friend the Secretary of State. That is a worry to my constituents and me, because we believe that the Government are absolutely sincere in their commitment to spending money on the NHS and spending it wisely.
	In addition to the pathway project, other hospitals will also be put on hold. I know that a similar decision has been taken at Barts, for example. I was telephoned yesterday by one of the Barts consultants, who is very concerned that the Leicester changes are being linked to what is happening in other parts of the country. So when the Minister responds, I hope that he can reassure me that the proposed reorganisation of Leicester PCTs—I understand the arguments in favour of such reorganisation, but it needs better justification—will not in any way affect the additional money coming in. I know that some of my colleagues do not favour private finance initiatives—they believe that they will somehow prove unhelpful to local people—but I favour them, because I will get a new hospital out of such expenditure.

Keith Vaz: I agree that such matters need to be put out to consultation, but as I have not stood as a European parliamentary candidate—or any other candidate, come to that—in that part of the country, I cannot comment on the configuration there. But it must be right for proper consultation to take place.
	That brings me to my final point: the proposed abolition of the ambulance service in my part of the east midlands and the creation of a new east midlands service. The hon. Member for Lichfield (Michael Fabricant), who is no longer in his place, and my hon. Friend the Member for Newcastle-under-Lyme (Paul Farrelly) were right to raise in this House their concerns about ambulance response times, and I have an example similar to the one given by my hon. Friend.
	I attended a funeral at the Gilrose crematorium, which is in the constituency of my right hon. Friend the Secretary of State. One elderly gentleman there was extremely upset, and he became very ill and collapsed. I telephoned the ambulance service and asked it to send an ambulance to take him from the crematorium literally down the road to Glenfield hospital, which is one of the finest hospitals in the country. I offered to take him in my car, but I was asked by the ambulance service operator not to do so unless I was a doctor, which clearly I am not. I said, "I am not a doctor, I am a Member of Parliament, so could you please send the ambulance as quickly as possible." An hour later, the ambulance still had not arrived. Exactly the same circumstances described by my hon. Friend with regard to for the London ambulance service applied to the ambulance service in my example.
	Hon. Members may ask why I would want to keep a service that did not respond quickly. Well, I want to keep the service because it is a local service. It is wrong to merge it into such a large area. It is only common sense that the response times will not be as quick as those for a local service.
	My very final point concerns the decision by the local health authority to close the Goodwood ambulance centre in my constituency. It is a brand new centre, near the Leicester general hospital. It houses several ambulances and enables them to get to local people much more quickly. The proposal is to close that ambulance station as part of a merger that will cover the whole of Leicester, with another centre built in another part of the city—or, indeed, of the county.

Mr. Speaker: Order. I am must be allowed to hear the Minister. I have to hear what he is going to say.

Andrew Mitchell: I am delighted to have secured this Adjournment debate regarding the behaviour of Network Rail towards my constituents in Sutton Coldfield. I have been in extensive correspondence with Network Rail and its chief executive, John Armitt, since 13 October 2004 regarding a line of grey stainless steel fencing that has been erected along a section of the freight line at East View road in my constituency. That fencing is ugly, does not fit in and is an eyesore.
	This is a story of arrogance and insensitivity, but, above all, of a complete lack of corporate accountability. East View road is a residential area in the green belt, located next to the picturesque New Hall Valley country park. It is an environmentally sensitive area and, although my constituents accept that they live next to a freight line and that line security is important, they do not accept the kilometre of monstrous, ugly grey steel fencing that has been erected. They want it to be replaced by green powdered fencing, which would be more suitable for the area. Network Rail has been asked to replace the grey fencing that it erected with more appropriate green fencing, but it has refused point blank.
	My constituents have been pursuing this point with Network Rail since March 2004 and I took up their case in October of that year. We have since been in frequent correspondence, and held a series of site visits and meetings—all to no avail. Network Rail has never truly engaged with the complaint or displayed any signs of sympathy towards the case. The arrogance and lack of interest that my constituents' complaint has received has been truly insulting. We can only conclude that Network Rail, although it states that it has an interest in being a responsible neighbour, has no intention of being anything of the sort. I therefore have no alternative but to highlight this sorry case to the House tonight. Network Rail has, through its behaviour, clearly demonstrated that its publicly stated environment policy and improved customer relations objectives are nothing more than box-ticking exercises. They hold no currency in the day-to-day business of Network Rail.
	In its stated key objectives, Network Rail claims that consultation with community groups, Government agencies and local authorities
	"is essential to our success."
	It continues:
	"We are rebuilding trust in the nation's rail network by listening to our customers."
	Network Rail's published environment policy, which was signed by John Armitt, the chief executive, in March 2003, claims to offer environmental safeguards. Its stated vision is to "achieve environmental excellence" by engaging in dialogue with stakeholders and to seek continual improvement in its environmental performance. The company claims:
	"We are committed to developing our relationships with the community and strive to be good neighbours across the areas in which we operate."
	There is no evidence whatever of that in the case of East View road.
	John Armitt is coming to the House next Monday to hold an MPs' "surgery" over line-side issues. I am sure that he is coming with every intention of promoting Network Rail's neighbourly credentials. However, if he did not feel that it was worth accepting my invitation to visit the East View road site and was unable to use his authority to address my constituents' problems, why should we think that that surgery is anything other than just another tick-box exercise, a cynical stunt straight from a public relations textbook?
	When one of Mr. Armitt's staff came to meet my constituents, after many requests, he was reduced to an embarrassed silence and was unable to defend the actions and attitudes of Network Rail in any way. He promised to go back to Network Rail to try to ensure that a fair and equitable solution was agreed. Nothing of the sort occurred. The subsequent letter that I and my constituents received was a muddle of smug, complacent bureaucracy that addressed none of my constituents' arguments.
	The views of the residents of East View road are being swept aside by the over- mighty Network Rail and their line-side issues simply ignored. Network Rail did not engage in any dialogue prior to the erection of the stainless steel fence, either with the local residents or the city of Birmingham planning office. The residents' first knowledge of Network Rail's plans to construct the fence was when they awoke to the sound of workmen cutting back trees, removing bushes and digging up the undergrowth before hastily putting up the fence. The residents of East View road only received correspondence from Network Rail after they had vociferously complained. A request for a temporary halt for a meeting to discuss the issue was rejected out of hand.
	Despite representations made by my constituents, Birmingham city council planning office and me to request the use of green fencing, it has refused in a most uncompromising, unsympathetic and offhand manner. The current grey fencing is acknowledged to be environmentally insensitive and completely inappropriate for areas in or around the green belt. At other locations in Sutton Coldfield, more suitable fencing of the green powder-coated variety is used. The question from my constituents is: why cannot they be treated the same as others and have appropriate fencing?
	Frustratingly, my constituents and I have no recourse to pursue Network Rail for breach of the local authority planning regulations, as Network Rail does not come under its jurisdiction. Birmingham city council planning control office confirmed on 22 June 2004 that the Town and Country Planning (General Permitted Development) Order 1995 allows Network Rail to carry out permitted work on its land without planning permission. Fencing does not therefore require planning permission, and Birmingham city council, whatever its view, has no power to intervene.
	Had the residents tried to put up such a fence, Birmingham city council would have insisted, due to the environmentally sensitive nature of East View road, as made absolutely clear by the city's planning policy, that the fencing must be green. There are innumerable examples of Birmingham city council having erected the sort of green powder-coated fencing that my constituents are seeking. For example, at the nearby Bishop Walsh school, which is also adjacent to the railway line and New Hall Valley park. The city council granted planning approval subject to the condition that the fencing would be powder-coated green. The reason for that condition is to
	"safeguard the visual amenity of the area".
	As a result all, security fencing fronting the highway in this locality is coloured green.
	The Walmley local action plan of May 2002, produced by Birmingham city council's planning department, declares:
	"the area does contain an historical legacy that is probably unique in the city. This centres on New Hall Valley and its listed buildings which represent a microcosm of a centuries old rural landscape and way of life".
	It also proclaims
	"This strategy is grounded in the widely accepted belief that the quality of the environment is of fundamental importance to the quality of life for local residents."
	Furthermore—this is highlighted in capital letters in the action plan:
	"Any Development proposed within the green belt will be strictly controlled to protect the character of the area and will only be approved if in line with the city council's more detailed guidance for green belts set out in the Birmingham plan."
	The plan identifies the area around the railway track as a wildlife corridor, and says that as such it requires careful consideration.
	According to the Walmley plan, any security fencing that is erected should be green, and whoever at Network Rail made the decision to use galvanised steel fencing had no regard for the local neighbourhood or for its own environmental policy. Birmingham city council did try to seek a voluntary solution, without success, finding Network Rail
	"to be unhelpful and unsympathetic".
	Network Rail has made a gross error of judgment in not treating the location with sensitivity and respect, and in not rectifying the clear errors that it made at the outset. It has been unable to give my constituents its reasons for not installing a green fence, despite having installed green fencing in other locations around Sutton Coldfield, including Mulroy road and Four Oaks station. Network Rail says that
	"the type and finish of the fencing was correctly assessed prior to its erection and given this it will remain".
	It has refused to give details of how the assessment was made.
	In August 2004, Network Rail suggested a compromise—that the residents paint the fence green themselves. Network Rail agreed to provide the paint, but the offer was later withdrawn on health and safety grounds. My constituents sought to use the Freedom of Information Act 2000 to obtain more information about Network Rail's green fencing policy, only to find that Network Rail was not classified as a qualifying body under the Act. However, the rail regulator—the Office of Rail Regulation, as a qualifying body—offered to try to obtain the information on behalf of my constituents.
	The ORR was told by Network Rail that it was under no obligation to release any information under the Act, and it therefore arrogantly refused to release any information relating to my constituents' request. My constituents asked the ORR whether it could force Network Rail to install green fencing in environmentally sensitive locations. The ORR explained that while it was sympathetic to the cause, it only set the contractual and financial framework within which Network Rail operates and was not involved in the details.
	This is a very difficult situation for my constituents. The residents of East View road have the impression that Network Rail is an uncaring, unaccountable and faceless organisation that can exercise its powers without challenge and in an arbitrary way, while ignoring any local resistance to its actions. The ORR has no direct control over Network Rail; it only provides a framework. The local planning authority has no powers, as Network Rail has permitted development rights. My constituents are unable to refer the matter to any third party for a review. They cannot refer it to an ombudsman, to an appeal body or to a judicial review. As for the Network Rail environment policy, it is policed by Network Rail itself and cannot be challenged. The key objective of improved customer relations set out by Network Rail has also been ignored. Network Rail has simply not listened to its stakeholders.
	It that context it adds insult to injury for my constituents that John Armitt, chief executive of Network Rail, received a salary of three quarters of a million pounds in 2005—£754,757, to be precise. If it goes up any more, we shall soon be talking serious money. His bonus was presumably not linked to the company's environmental policy targets.
	It is my strong contention, having regard to the sensitivity of the location, and in line with Network Rail's fencing policy in Mulroy road, Wylde Green road, Station approach, Bowlas avenue and Lichfield road close to Four Oaks railway station, that the fencing in East View road should be fully replaced with green powder coated fencing. However, I acknowledge that there are significant cost implications. I want to be helpful, constructive and suggest a compromise solution. Instead of removing the whole fence and the posts supporting it, which is where much of the expense would arise, it should be perfectly feasible to remove just the panels themselves, which are simply bolted on, and it would take just minutes to remove each one. The original support posts could remain and new green powder coated panels bolted on. The existing silver grey fencing could be reused elsewhere, although only where appropriate and not in an environmentally sensitive area such as this.
	Network Rail should put an end to the sorry situation and work with the community in East View road, respecting their environment and their opinions to find an acceptable solution. No MP would stand for such arrogant treatment of their constituents, which is why I bought the case to the House.
	We look to the Minister, who has in the past shown sensitivity on these issues, to call in the chief executive, to remonstrate with him over the way in which my constituents have been treated, to remind him and Network Rail of their environmental obligations—not least those obligations set out by Network Rail itself—and to make it clear that, as the Minister responsible for Network Rail, he does not expect to see that high-handed and arrogant behaviour replicated anywhere else.

Derek Twigg: I congratulate the hon. Member for Sutton Coldfield (Mr. Mitchell) on securing the debate. It is clear from his remarks that this is a matter of ongoing concern in his constituency. I thank him for the information that he provided before the debate, which has been helpful in preparing the response to the important matter that he has raised.
	Before dealing with the specific issue, I would like to say a few general words about Network Rail and its structure, objectives, responsibilities and priorities. Network Rail is a very large organisation and has a diverse and extensive portfolio of land and property. It employs more than 30,000 staff and owns and maintains 21,000 miles of track. Network Rail's priorities must be focused on the effective management of the rail network. Its first priority is to operate a safe, reliable and affordable railway.
	The hon. Gentleman is concerned that Network Rail is not accountable to Ministers and that it is unclear to whom it is accountable. In truth, Network Rail has a large number of stakeholders, and I will say more about that shortly.
	The concerns in Sutton Coldfield arise from the installation of new line-side fencing. The main reason for that is to improve safety and to prevent trespass on the railway. The primary responsibility for preventing trespass on the national rail network lies with Network Rail. In doing that, Network Rail works closely with the British Transport police, the Department for Transport and others in the rail industry and the wider community.
	Network Rail's national fencing programme is designed to reduce the scope for unlawful access to the rail network, and is recognised as a good initiative. I note that neither the hon. Gentleman nor his constituents dispute the need for fencing along East View road.
	The hon. Gentleman raises concerns about Network Rail's lack of accountability to local planning authorities, in particular with regard to planning policies about the colour of fencing. As a statutory undertaker, Network Rail enjoys permitted development rights, under part 17 of the Town and Country Planning (General Permitted Development) Order 1995, for development on its operational land required in connection with the movement of traffic by rail. Statutory undertakers have acquired such rights for very good reasons. They provide an essential service to the public. It would therefore be unreasonable and inefficient to require them to make a planning application for essential development each time they needed to build something on their operational land.
	The Office of the Deputy Prime Minister is carrying out a review of the permitted development order arising from its 2002 Green Paper outlining proposals for fundamental reform of the planning system. The review included a research study of the permitted development rights available to railway undertakers. Following publication of the study in September 2003, ODPM will undertake a public consultation before implementing any proposed changes to current rights.
	I would like to go into more detail about Network Rail's status and responsibilities. Network Rail is a private sector company operating on a commercial basis. It is a "company limited by guarantee". It has no shareholders and so does not have to earn dividends to pay them. Instead, any surplus it makes can be reinvested in the rail network for the benefit of all.
	I think that at this point it would be worth explaining the new railway structure following the Railways Act 2005. The changes are vital to drive up standards, improve overall performance and underline who is best placed to deliver. The Government have taken charge of setting the strategic direction of the railways. In future, the Government will decide the high-level outputs they wish to buy from the railway and the public sector funding available for this.
	Network Rail has been given clear responsibility for operating the network, and for its performance, timetabling and route utilisation. Train and track companies are working more closely together through the introduction of joint control rooms. The Office of the Rail Regulation now covers safety, performance and economic regulation. As part of being a company limited by guarantee, Network Rail's board is accountable to its 100-plus members. These are drawn from the industry and wider rail stakeholders including local and regional bodies, passenger groups as well as individuals. The Department for Transport is also a member.
	Network Rail's members hold the board to account as shareholders would do in a PLC, although of course they have no financial interest in Network Rail. They appoint and reappoint directors, approve directors' remuneration and agree the company's annual report and accounts, but they do not get involved in the running of the company. Network Rail's priorities inevitably must be focused on the effective management of the rail network. Its first priority is to operate a safe, reliable and affordable railway and securing the network plays an important part in achieving this goal. However, Network Rail must also strike a balance between operating a safe and reliable railway and addressing environmental and community concerns.
	Network Rail is accountable to its regulator, the Office of Rail Regulation. The ORR ensures that Network Rail sticks to the terms of its licence in running the network. If it thinks it is not doing a good enough job, it can take—or consider taking—enforcement action against Network Rail. The ORR also sets the income that Network Rail should receive and the outputs it must deliver for that income. Network Rail is also accountable to its major funders—the Secretary of State and, from April this year, Scottish Ministers. It must be for Ministers, who are accountable to Parliament, to set the national strategy for the railways. Under the new arrangements implemented by the Railways Act 2005, the Government will set the level of public expenditure and take the strategic decisions on what this should buy.
	Network Rail is accountable to its local communities. The company owns 21,000 miles of track. That is a lot of neighbours, including, of course, those in the hon. Gentleman's constituency. Despite the problems in his constituency, I welcome Network Rail's ongoing engagement with wider communities and its initiatives against railway trespass; for example its innovative "No messin!" campaign last summer to warn youngsters of the dangers of "playing" on the network, and targeted at route crime hotspots.
	I am glad to see that the chief executive of Network Rail is actively engaging with hon. Members through the planned "line-side surgeries." I understand the concerns that the hon. Gentleman has raised, but it is a good initiative. I also believe that Network Rail is concerned about the local environment.
	The hon. Gentleman raised concerns as to whether Network Rail's responsibilities to its neighbours fell short of what was expected in this instance. I very much hope the concerns of his constituents about the type and finish of the fencing can be resolved to everyone's satisfaction. But subject to Network Rail complying with the terms of its licence and relevant statutory requirements, we have no powers to intervene in operational decisions. Except in a limited range of circumstances related to security or major emergencies, Ministers have no powers to issue directions or any other binding instructions to Network Rail.
	I shall certainly bring the concerns that the hon. Gentleman has raised, and his compromise proposal, to Network Rail's attention and ask it to respond directly to him.
	Question put and agreed to.
	Adjourned accordingly at sixteen minutes to Eleven o'clock.